S 0457Boot tCANTTn ED 1 IN INEnRMATInN WITHIN REn LINES - USE BALL POINT PEN ONLY
OFFICE
CITU OF CUPERTINO - BUILDING. - ELKCIRICAL
BUILDING DIVISION APPLICATION/PF,RMITPLUMBING- MECHANICAL '
ItUILDING PROJECT IDENTIFICATION
PERMIT NO,
S 0157
BUILDING ADDRESS: -
Z'i�30 5 :TuA-m) 3,0
SANITARY NO,
APPLICAI'FON SUBMITTAL DATE
Gil' Aq
OWNER'S AMI?.
A?V, WA{. (P'HO ::- �k
G. J C /Vd
RCfIITECT/ENC NEER: LIC NO:
CO TRAC ORN NAM1i: '[C NO
& /• S / (_5
%DDH&A sItIl � Or 2Z69 l 4
44 JJ11:://
NIC
❑
L TROT,p
[pT`�It//Ix It
CONTACT PHONE:
CC'jRA-C) 4/ �— o- s
ZX0LICENSED
❑ Consultant Fecs Paid by Applicant (Initial)
BUILDING PERMIT INFO
R ELE PL MB �l
CONTRACTOR'S DECLARATION
- 1 hereby orm that I ant licensed under.... it to is of Cnaplcr 9 (commencing
ff
witnse9nnn]Dm)nromixmn3.nneBaamesaanaProres.mnao,de.andtttyuaensei.a
in full force and cRat. � Los
License Class Lick
Date Contractor
QTY. ELECTRIC PERMIT FEE:
JOB DESCRIPTION
R m
❑SFDWL ❑KITCHEN REh10D131.
❑ADDI'T'ION [I PLUMBING RIi-PIPIT
❑STRUC'TURAL
MODIFICATION
ElINTHI(IOR ❑CHIMNEY REPAIR
IMPROVEMIiN'I' ❑ SWIMMING POOLS
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ (Yflllilt
I'z
10
)UU
W
.a
l m
e
I
cul
i
. F-
o�which
j0
i
.}
Cq
:w
PERMIT ISSUANCE
APPLIANCES-RESIDEN'r1AL
ARCHITIiCTS DECLARATION❑MULTI-UNIT
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER D' mo Cs ATION
1 hereby affect Inn I nm exem" faun Tho Canmam Cana Licensor latw for the
Realness and improve, do inns Coon Any city s county
following reason. Ignition 7031.5. constrict,
requiresm permit re c.mtua, a0eq improve, dem-it I ti repair any stmaurc
prior to its issuance, also rcyuires the applicant for such permiuntilnn signed seatemmit
tnat he is licensed pursuant to the powisions of the Cont -10111 s License Law (Chapter 4
(commencing with Seen..9000)of Division 3mf the Businessand Prnfesslonv CMc)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit snhjects Ibe applicant to a civil peva ly of
not mom than fee hundred dollars S5(10).
will Ldoas thoewwneorrko,f utnhJe ePM1me pstenucy,worre misY nemmiw oir penweion,
mrm1rdorodfTcmdfcmlx(Srs.7(
and Professions Code: The Cenemcmrs Liccnae Law does not apply to an owner of
PAN17M
UPTO200AMPS
201-I(00AMPS
OVHR 1000 AMPS
SIGNS ELECTRICAL
SPF.CIAI. CIRCUIT/A11S
IEMP.MITTEROR LHINST.
AL
COMMERCIAL
[I NEW BLDG/ADDITION [I DIiAfOLI'I'ION
❑'fBNANT ❑FOODS ?kVICE
IMPROVEMI:NT
OTIII:R
POWER DEV/S
SWIMPOOL ELECTRIC
0,500.!'I'S -SWITCHES - ITXTUItCS
propeny who builds or improves thereon, and who does such work himmlf or through
his we employees, provided that such improvements art not intended or offered for
sale. l[ however. thebuddiagorlmprovemont is sold within one yearof completion, the
NEW RESIDF.NI'IAL ELECTR SQ FT.
SQ. PT. PInOb1RRl��
S/SQ. FI'.
-
caner -builder will have the burden of proving that he did not build or improve for pur-
pose mf ode.)
❑ 1, us nwaer al the prnpenY, net exclusively common, wi0 Isotood enmmetnrx lo
construct the project (Sec. 70et Business and Professions Code:) The Contractor's U.
come Law does nor apply it) an owner of pmpcny who builds or improves thereon,and
'TOTAL:
JUN 28
- -
QTY PI.UMRING PERMI FEE
who contracts fin - such pm,jects will, n coneractnpursuant r(s) licensed pursuano the Common, s
License law.
❑ I an exempt under Sec. ,B& P C for this reason
CITY ur Wil"ERTN
PER VU r ISSUANCE
Owner Date
ALTAR- DRAIN & VENT- WAT17R LA)
VALUATION
/�C�{/%]—+
�� ` _
WORKERS COMPENSATION Dfthe
BACK FLOW i'ROTECT. DEVICE
(RATION
I hereby affn under penalty of perjury one of enc following declarations:
i or
❑... as and will forbineCention ficale37W of Convent Code, for the Worker'sre of be
ration, as provided for mi Ss i... 3]W of the Labor Code, for the pedomtance of the
work for which chis permit is issued.
DRAINS -FLOOR, ROfIh.AREA, COND.
STORIIiS
'TYPECONSTRUCI'I(lN
FIXTURES -PER TRAP
have and will maintain hPerfWorker's ante ofthe w Insurance, h required by Section
3]011 nl the Labor Code, fnr the perliemenve of the work for which this pcnnie is lsxuaL
OCC GROUP
AI'N
GAS -EA.SYS 'I'IiM-I INC. 40U' ATS
My Workers Compensation Imuraace Pander and Policy number am:
Ci,picr: Policy No.:
GAS - EA. SYSTEM-OVI!R ITA)
GRIiASPJINI]DSTRI. :'I'F.IN'I'IiRCEPfOR,
CERTIFICATE OF EXF.MVI'ION FROM WORKHRS'
COMPHNSATION INSURANCE
HUHIANO DIVISION FEE'
(This section need not he completed if the permit is for one hundred dollars IS 1 WE
or Ices.)
GREASETRAI'
I'LANCHIiCK FEE
SEWER -SA fARY-S'1 ORM ITA. 200 FI'.
Ieenify1lonarheperformareofllewnrkfnrwhichthispeareheisxuad,Ishall
not employs yyargon in en a o lune suhjecuo Ie We, ci-C nmpen
IiNERGY TEF.
WATER .A'1'IiR WNIiM]ELECTR
f RADINQ FF.F
,Z,
(A
Video La . of CaIfi ►
Applies
NOT A' 11 ANTE. . crm :ing this enificale 1'Exe tion, you should
m due e Worker's Compensation provisions of the Lalasr Code, you must
JAX SYS, RMITRF.AI'ING
SOILS ITH
AI'IiR SERVICE,
o .amply with such pmvisinnx or This pemtit ahall be AectncA revoked
O
,'Z
L1
CONSTRUCTION LENDING AGENCY
thus (here in se.construction0 7, Cing agency for the Performance of
I hor which
the work for which this pennie is issued (See. lFW], Civ. CJ
IanJeh Name
PAID
Date Receipt M
NEW RISIDIiNT1AL PLM. SQ. FT.
TOIAI"
'TOTAL:
Lender's Address
Information i.
Ii IJILDING FEE d
1 cannily that I have read this appl'a niion and store that the above
correct. I a green, comply with all city and ecromyor dunces and sme, laws relating to
building consuuceion, and hereby aphorize representatives of this city e. enmr upem the
QTY. MECHANICAL PIERMIT FHE
SEISMIC FEE
.720
PERMIT ISSUANCE
ELECTRIC IsEC
nhave-intentioned property for inspection purposes.
and
(We) agree to save, indemnify keep hamdess the City of Patent.. against
ALTER OR ADD TO MECH.
PLUMBING FF.F.
liabilities,judgments,cost.imdexpenses which may in anywayaccme againstsaid City
in asequence of the granting of this permit
AIR HANDLING UNI'I'1'TO 10,000 CFM)
MECHANICAL FIJI
APPLICANT UNDERS'PA 'ILL COMPLY WITH LLN N -POINT
REGULA
AIR HANDLING UNIT (OVER 111,000 CF5111CONS'TRUCIION
FAX III
7
ceor Date
HAZARDOUS MATERIALS DISCLOSURE
BXHAUSTHOOD(W/DUCT)
HOUSING MITIGATION EE
HEATING LINE r(TO 100,030 B' )
WIIl the opplictimor future building occupant stoner handle hvanlmrsmmariul
as defined by the Cupertino Municipal Codt,. Chapter 9.12, and the Health end Safety
Code. Section 25532(a)?
HEATING ON IT(OVIiR 1 Bld)BTU)
/61 1aV1.11
VEN'1'IhATION FAN/NG LH RISIU)
F-1 yes ❑Nn
Will the applicant or future building occupant use eyuipmenl or devices which
emit hazardous air contaminants as demand by the Bay Area Air Quality Management
P 1
tae eceipt
BOILER -COM 7HI'OR I W,INp BTU)
TOTAL:
ROILIiR- PIOVIIR 1001X111 HTU)
DisvicYt
C] Yes ❑Nn
AIR CO ITIONER
I have rend the hazardous nmmnah, nommmenss under Chupterfi 95 of he Cali-
ISSUANCE DATE
NE REST DEN'I']AL MHCH. SQ, PT.
fomm Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand that if the
Tiding doeor s ncurrently have a tenant, chat it is my responsibility ,, notify the cecupant
olden requirements which must be met prior at issuance of a Cerifeate of Occupancy.
k
ISSUER 114:
TOTAL:
Owner or authorized agent Date
OFFICE